Audits of Medicare Plus Blue^SM PPO professional claims begin April 2018

On April 1, 2018, HMS^® and SCIO Health Analytics^®, independent companies supporting Blue Cross Blue Shield of Michigan, will begin auditing Medicare Plus Blue^SM PPO claims for professional services. This applies to all professional providers who bill CPT and HCPCS codes.

The auditors will look back two years and review specific claims or projects to confirm that you’ve properly billed and documented requirements for your billed services. Specifically, they’ll ensure that billed and paid services were ordered, medically necessary, documented, reported and covered under the patient’s contract, according to Centers for Medicare & Medicaid Services guidelines.

Besides ensuring that billed services were medically necessary, provider audits:

• Confirm compliance with HCPCS and CPT codes in effect on the date of service.
• Detect, prevent and correct waste and abuse.
• Support accurate claim payment.

Health care providers will be notified of upcoming audits through a medical chart request letter. In the letter, they’ll be informed of what claims are part of the review, what we’re reviewing for and the time frame during which they can respond to our request.

At the time of an audit, you’ll want to be prepared to share medical charts for review. After the audit, HMS or SCIO Health Analytics will send you a letter with the findings and information on how you can seek an appeal, if necessary.

During an audit, if you need to speak to a SCIO Health Analytics representative, call 1-866-628-3488. If you need to speak to a HMS representative, call 1-866-875-1749. If you have any general questions about the audit process, you can reach out to your provider consultant.